Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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Unfortunately, injuries cause more than pain and lost playing time for athletes. In many cases, an injury negatively impacts self-esteem and creates fear and anxiety. For competitive athletes, the injury often separates them from their familiar role and identity with respect to their teammates, coaches and peers.
It seems rather obvious that injured athletes would want to return to sport as soon as possible, right? Based on my clinical observations and experience, most athletes are motivated to return after their first injury. The more serious the injury (e.g. ACL tear, Achilles tendon rupture or UCL tear), the longer the road to get back. The speed and ease of the process is affected by the patient’s response to injury and surgery (coper vs. non-coper), degree of injury, skill of the surgeon, effectiveness of rehab, and patient compliance.
Much of the research done to date with fear of re-injury has centered on athletes undergoing ACL reconstruction. Over the last decade, methods for measuring kinesiophobia (fear of movement associated with sport/injury) such as the Tampa Scale of Kinesiophobia. I routinely use the TSK-11 with my athletes. In addition, the ACL-RSI is another tool for evaluating psychosocial readiness to return to sport. As sports medicine practitioners, we must pay attention to our clients’ fears and mental status.
Invariably, not all athletes want to return to sport. Factors that may hinder return to sport are:
- Chronic pain
- Fear of re-injury
- Fear or anxiety about long term pain, injury or future disability (such as osteoarthritis)
- Anxiety about not being able to return to their prior level of performance
I came across some very good reads on Twitter last week week that I wanted to pass along. The first is a blog post by Rich Willy, a PT, professor and researcher who specializes in running and running related injuries. If you or any of your friends have suffered from nagging IT Band pain, this is a must read. In this post, he discusses proper treatment strategies:
The second pearl involves long toss and force on the elbow. Ever wonder how advising a pitcher to reduce his throwing intensity actually impacts velocity and torque on the elbow? It seems that decreasing effort level by 25% and 50% does not equate to the same reduction in actual velocity with a study using the motus sleeve. Read more below:
Baseball Pitchers’ Long Toss Perceived Effort & Actual Velocity
Finally, there has been much discussion about return to sport assessment after ACL reconstruction. Lately, many have begun to question how effective hop testing really is when it cones to determining readiness to return to sport. I use several assessments (one of which is hop testing), but I also feel psychological readiness is crucial.
This article sheds light on the connection between proper single limb landing mechanics and psychological readiness.
Association of Psychological Readiness for RTS after ACLR and Hip and Knee Landing Mechanics
Unfortunately, too many athletes who recover from ACL tears go on to suffer another injury within a short period of time. Click here to read a prior post on secondary injuries. There are differing opinions on when or if there is an exactly “right time” to clear an athlete for return to play.
We already know that athletes have persistent weakness and asymmetry at 1 year post-op and even beyond. I recently had one of my collegiate soccer players re-tear while helping out with a youth soccer camp. She had not yet done hop testing with me or been cleared for full soccer, but as she was 1 year out she did not think it would be an issue playing with 12 year-old girls. It only took 20 minutes before she suffered a non-contact re-injury and lateral meniscus tear.
Consider the following paper that reveals low rates of patients meeting return to sport (RTS) criteria at 9 months post-op:
https://www.ncbi.nlm.nih.gov/pubmed/29574548
Another paper recent published in the Journal of Sports Rehabilitation revealed marked deficits in balance and hop testing at 6 and 9 months post-op:
https://www.ncbi.nlm.nih.gov/pubmed/29466066
A recent paper in the American Journal of Sports Medicine (https://www.ncbi.nlm.nih.gov/pubmed/29659299) lists positive predictors of a return to knee-strenuous sport 1 year after ACL reconstruction were male sex, younger age, a high preinjury level of physical activity, and the absence of concomitant injuries to the medial collateral ligament and meniscus.
In 2016, research in the American Journal of Sports Medicine revealed delaying return to sport at least 9 months markedly reduced re-injury risk in those who passed RTS testing. Click below for more on that study:
https://www.ncbi.nlm.nih.gov/pubmed/27162233
So, where are we now? I employ multiple functional tests including the Y-Balance Test, FMS, single leg squatting, hand held dynamometry, hop testing, qualitative movement assessment and jump landing assessments. But, is that enough?
Have you ever experienced a significant injury? If so, do you remember wondering if you would ever be whole again? Pain, fear and the inability to do your sport or physical activity can cripple the human spirit.
Over my 21 years as a physical therapist and fitness professional, I have witnessed how powerful the mind is and how critical it is to have the right mindset to overcome physical obstacles. Some people are mentally stronger than others – period. With that said, adversity and pain has a way of testing the spirit and will of an individual.
In any given week, I see at least 5-10 patients rehabbing an ACL injury. The injury, surgery and rehab is physically and mentally grueling. The injury itself takes the athlete away from his/her passion or sport immediately, while presenting them with a long path back to full health. Many suffer an identity crisis as they become isolated and away from their peers. Physical therapy that fully restores function is a must in this group of patients. For more on what complete ACL rehab looks like, click here to read one of my previous posts.
Fear of reinjury and persistent knee symptoms are common reasons for a lack of return to play after ACL reconstruction. Click here to read an abstract regarding kinesiophobia in this group of patients.
With any injury, it is only natural to worry about the outcome. Clients often wonder quietly whether they will be able to return to their previous level of play. In this post, I want to talk about the elephant in the room for patients coming back from an injury, and that is a legitimate fear of reinjury.
Poor landing mechanics are often cited as a predictor of ACL injury risk. In my 20 years as a physical therapist, I have rehabbed many athletes with this injury. I believe that injury prevention, whether to prevent a primary or secondary injury, hinges on the ability to train the body to decelerate and land appropriately. Some athletes simply move better than others. Nonetheless, teaching a soft bent knee landing while minimizing dynamic valgus is essential.
The following video from my online PFP column reveals a foundational exercise that can be used in prevention and rehab alike.
Click here if you want to read about another landing exercise that I utilize in my training and rehab programs.
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